Basic Information
| Provider Information | |||||||||
| NPI: | 1376652933 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VANARSDALL FAMILY OPTOMETRY P C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1033 JACKSON ST STE C | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472015769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123763068 | ||||||||
| FaxNumber: | 8123766771 | ||||||||
| Practice Location | |||||||||
| Address1: | 1033 JACKSON ST STE C | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472015769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123763068 | ||||||||
| FaxNumber: | 8123766771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 04/30/2010 | ||||||||
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| AuthorizedOfficialLastName: | VANARSDALL | ||||||||
| AuthorizedOfficialFirstName: | KEN | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER / PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8123763068 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 56000172A | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 100083400A | 05 | IN | MEDICAID | 22000000103899 | 01 | IN | ANTHEM | OTHER | 56000172A | 01 | IN | LICENSE REGISTRATION NUM | OTHER |